Wisconsin Department of Safety and Professional Services
Health & Business Renewal Application
Application Status Query
Instructions:
Please allow one hour after receipt of your status update email for the updates to be reflected in the online checklist.
Please verify the checklist information below, including your address. If your address has changed, please
e-mail
your application number, name, profession, along with your old and new address. The Credentialing department posts status information following receipt and review of application materials.
As of
:
06/26/2015
Application#
:
542365
Name
:
Faiza, FNU
Profession
:
Resident Educational License
Address
:
Tampa, FL
Application Status
:
Withdrawn (Abandoned)
Requirements Not Met:
Description
Status
Comments (Please note, not all requirements will include comments)
Affidavit of Hospital Authority Form #2601
Not Met
Requirements Met:
Description
Status
Comments (Please note, not all requirements will include comments)
Application Fee
Met
6/26/15: Rec'd Fee;
-----
6/18/15: Please remit $10.00 application fee. Please print a copy of this page and return to our department with the $10.00 payment to DSPS, PO BOX 8935, MADISON WI 53708-8935 $10
Application Complete
Met
6/18-DCF form processed - MLS-6/18/15: DCF Form Sent to renewal for processing.
All activities and practice accounted for from the date of graduation to the present. Provide hospital name, location (city&state) and beginning and ending dates (month&year)
Met
6/24/15: Complete;
-----
6/17/15: From 3/05 to 6/06, 6/09 to 2/12 and 4/12 to 2/13; This time frame was not accounted for on the application. All time must be accounted for including professional and non-professional activities. Time must be given in mo/yr format for start/end dates & include name of facility, location (city/state/country) & type of activity (i.e. Post-Grad, Practice, Privileges, Employment, Appointment, etc). You can fax info to 608-261-7083
Certification of Legal Status Completed
Met
Affidavit of applicant, signed
Met
Certificate of Professional Education Form #3050
Met
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